"Specific, encouraging help every parent needs and every child wants." - Dorothy Rich, Ed.D., author of MegaSkills: The Best Gift You Can Give Your ChildThe Myth of the A.D.D. Child is the first book of its kind to challenge the misdiagnosing of millions of children with attention-deficit disorder and to question the overuse of psychoactive drugs in treating hyperactivity. Thomas Armstrong is a psychologist, teacher, and consultant who has had years of experience working with children with attention and behavioral problems. He believes that many behaviors labeled as A.D.D. are in fact a child's active response to complex social, emotional, and educational influences. By tackling the root causes of these problems- rather than masking the symptoms with potentially harmful medication and behavior-modification programs-parents can help their children experience positive changes in their lives.
Dr. Armstrong offers fifty non-drug strategies for helping a child overcome attention and behavioral problems. These include activities for increasing self-esteem and making the most of vitality and creativity. He also provides a checklist to find the interventions that are best for a particular child, and hundreds of resources- books and organizations that support these fifty strategies. Provocative and persuasive, The Myth of the A.D.D. Child is a practical, essential guide for both parents and professionals.
A.D.D.: The Disorder That Goes "Poof!"
By stating that A.D.D. is a medical disorder, experts are placing the source of the problem inside of the child. Yet, unlike other medical diseases, such as diabetes or pneumonia, this is a disorder that pops up in one setting, only to disappear in another. A physician mother with wiggly kids of her own wrote to me not long ago about her frustration with this protean diagnosis: "When I ... began pointing out to people that my child is capable of long periods of concentration when he is watching his favorite sci-fi video or examining the inner workings of a pin-tumbler lock, I notice that the next year's definition states that some kids with A.D.D. are capable of normal attention in certain specific circumstances. Poof! A few thousand more kids instantly fall into the definition."
There is in fact substantial evidence to suggest that children labeled A.D.D. do not show symptoms of this disorder in several different reallife contexts. First, up to 80 percent of them don't appear to be A.D.D. when in the physician's office. They also seem to behave normally in other unfamiliar settings where there is a one-to-one interaction with an adult (and this is especially true when the adult happens to be their father). Second, they appear to be indistinguishable from so-called normals when they are in classrooms or other learning environments where children can choose their learning activities and pace themselves through those experiences. Third, they seem to perform quite normally when they are paid to do specific activities designed to assess attention. Fourth, and perhaps most significantly, children labeled A.D.D. behave and attend quite normally when they are involved in activities that interest them, that are novel in some way, or that involve high levels of stimulation. Finally, about 50 percent of these children reach adulthood and discover that the A.D.D. apparently just goes away. Poof!
It's understandable, then, that prevalence figures for A.D.D. vary widely, far more widely than the standard 3 to 5 percent figure that popular books and articles use as a standard. As Russell Barkley points out in his classic work on attention deficits, Attention Deficit Hyperactivity Disorder - A Handbook for Diagnosis and Treatment, the 3 to 5 percent figure "hinges on how one chooses to define ADHD, the population studied, the geographic locale of the survey, and even the degree of agreement required among parents, teachers and professionals.... Estimates vary between 1-20 percent." In fact, estimates fluctuate even more than Barkley suggests. In one epidemiological survey conducted in England, only 2 children out of 2,199 were diagnosed as hyperactive (0.09 percent). Conversely, in a study in Israel, 28 percent of children were rated as hyperactive by their teachers. And in an earlier study conducted in the United States, teachers rated 49.7 percent of boys as restless, 43.5 percent of boys as having "short attention span," and 43.5 percent of boys as "inattentive to what others say."
This difficulty in finding any real attention deficit in "A.D.D. kids" has led some researchers in the field to propose that maybe these kids don't have attention deficits at all! In addition, some researchers are proposing new ways of helping to explain the "A.D.D. child's" often puzzling behavior. Russell Barkley, for example suggests that these kids may have specific deficits in what he calls "rule-governed behavior." In this view, A.D.D. children are considered to be less responsive to rules established by authorities, and less sensitive to the positive or negative consequences that authorities set down for them in advance. They're less likely, for example, to respond positively to statements like "If you get out of your seat, then I will keep you in during recess" or "If you stay in your seat, then I will give you a prize at the end of the day." In other words, kids labeled A.D.D. will not play the game set down by the rule-making parents and teachers.
While a certain amount of rule-following is necessary to maintain the social order, it's not always advantageous to be a rule-follower. Witness the classic example of superobedience in Nazi Germany. Closer to home, Yale psychologist Stanley Milgram's experiments in obedience suggest that human beings have a frightening capacity to follow orders when given by a respected authority. Milgram had volunteers administer "electric shocks" to a subject in a control room every time the subject made an error on a learning task. With each subsequent error, the "voltage level" was increased. Despite protests from the subject, the volunteers were ordered to proceed to higher levels of voltage. Statements like "It is absolutely essential that you continue," and "You have no other choice: you must go on," were used by the experimenter in charge to pressure the volunteers into continuing to shock the subjects. In actuality, no real shock was given. The subject only pretended to be in pain. But the volunteers didn't know that, and fully 65 percent of them showed total obedience in administering the full range of shocks. One wonders, then, why there isn't a parent advocacy group or professional organization designed to treat overly compliant children. These children would seem to be a far greater threat to civilization than children who have problems with "rule-governed behavior."
The A.D.D. myth is essentially a paradigm, a worldview, that has certain assumptions about human beings at its core. Unfortunately, the beliefs about human capacity addressed in the A.D.D. paradigm are not terribly positive ones. It appears as if the A.D.D. myth tacitly endorses the view that human beings function very much like machines. A.D.D., in this perspective, represents something very much like a mechanical breakdown. This underlying belief shows up most clearly in the kinds of explanations that parents, teachers, and professionals give to children labeled A.D.D. about their problems. In one book for children entitled Otto Learns About His Medicine, a red car named Otto goes to a mechanic after experiencing difficulties in car school. The mechanic says to Otto: "Your motor does go too fast" and recommends a special car medicine.
While attending the CH.A.D.D. national conference, I heard A.D.D. experts share similar ways of explaining A.D.D. to kids, including comparisons to planes ("Your mind is like a big jet plane.... You're having trouble in the cockpit"), a car radio ("You have trouble filtering out noise"), and television ("You're experiencing difficulty with the channel selector"). These simplistic metaphors seem to imply that human beings really aren't very complex organisms and that one simply needs to find the right wrench, the proper gas, or the appropriate circuit box-and all will be well. They are also just a short hop away from more insulting mechanical metaphors (e.g., "your elevator doesn't go all the way to the top floor").
The other feature that strikes me as being at the heart of the A.D.D. myth is the focus on disease and disability. I was particularly struck by this while attending a workshop with a leading authority on A.D.D., who started out his lecture by saying that he would treat A.D.D. as a medical disorder with its own etiology (causes), pathogenesis (development), clinical features (symptoms), and epidemiology (prevalence). Proponents talk about the fact that there is "no cure" for A.D.D., and that parents need to go through a "grieving process" once they receive the "diagnosis." A.D.D. guru Russell Barkley commented, in a recent address, that "although these children do not look physically disabled, they are neurologically handicapped nonetheless.... Remember, this is a disabled child." Absent from this perspective is any mention of a child's potentials, strengths, talents, abilities, gifts, and other manifestations of health: traits that are crucial in helping a child achieve success in life.
Naturally, in order to make the claim that A.D.D. is a disease, there must be a medical or biological cause. Yet like everything else with A.D.D., no one is exactly sure what causes it. Possible biological causes that have been proposed include genetic factors, biochemical abnormalities (imbalances of such brain chemicals as serotonin, dopamine, and norepinephrine), neurological damage, lead poisoning, thyroid problems, prenatal exposure to adverse drugs and environmental agents, and delayed myelinization (insulation) of the nerve pathways in the brain.
In its search for a physical cause, the A.D.D. movement reached another milestone in its development with the 1990 publication in The New England Journal of Medicine of a study by A. J. Zametkin and his colleagues at the National Institute of Mental Health. This study appeared to link hyperactivity in adults with reduced metabolism of glucose (a prime energy source) in the premotor cortex and the superior prefrontal cortex - areas in the brain that are involved in the control of attention, planning, and motor activity. In other words, these areas of the brain were not working as hard as they should have been, according to Zametkin. The media picked up on Zametkin's research and reported it nationally. A.D.D. proponents latched on to this study as "proof" of the medical basis for A.D.D. Pictures depicting the spread of glucose through a "normal" brain compared to a "hyperactive" brain began showing up in CH.A.D.D. literature, and at CH.A.D.D. conventions and meetings. One A.D.D. advocate seemed to speak for many in the A.D.D. movement when she wrote: "In November, 1990, parents of children with A.D.D. heaved a collective sigh of relief when Dr. Alan Zametkin released a report that hyperactivity (which is closely linked to A.D.D.) results from an insufficient rate of glucose metabolism in the brain. Finally, commented a supporter, we have an answer to skeptics who pass this off as bratty behavior caused by poor parenting."
What was not reported by the media, or cheered by the A.D.D. community, was the report that came out three years later by Zametkin and others in the Archives of General Psychiatry, attempting to repeat the 1990 study with adolescents. In that study, no significant differences were found between the brains of so-called hyperactive adolescents and the brains of so-called normal adolescents. And in retrospect, the results of the first study didn't look so good either. For example, a recent critique of Zametkin's research by faculty members at the University of Nebraska also pointed out that the study did not make clear whether the lower glucose-metabolism rates found in "hyperactive brains" were a cause or a result of attention problems. They pointed out that if a group of subjects were startled and then had their levels of adrenaline monitored, adrenaline levels would probably be quite high. We would not say, however, that these individuals have an adrenaline disorder. Rather, we'd look at the underlying conditions that led to the finding of abnormal adrenaline levels. Similarly, even if biochemical differences did exist in the so-called hyperactive brain, it may be that such differences become disorders only when combined with specific environmental factors. Thus, instead of searching for "the A.D.D. brain," researchers ought to be more concerned about describing the interaction of different kinds of brains to stress, parenting style, classroom structure, and other environmental influences (see Chapter 3 for a discussion of some of these factors).
You may be wondering at this point how A.D.D. has come to gain such wide respect in the past few years when there is so little evidence to support it. The fact is, A.D.D. fulfills a number of important needs among parents, teachers, and professionals. Perhaps most significantly, the term attention deficit disorder gives parents and teachers a relatively simple way of explaining troublesome behaviors. Many parents of kids who've been labeled A.D.D. speak gloomily about the years preceding diagnosis. These stories often reveal long periods of personal turmoil during which parents took their children from one specialist to another, only to be given different opinions about the nature of the problems involved. "He'll grow out of it," says one professional. "It's a vitamin deficiency," declares another. "He needs to buckle down in school," counsels an administrator. "You're being too soft on him at home," advises a mother-in-law. Parents who have floundered for years in trying to cope with their child's difficult and puzzling behaviors now have a simple term to use in describing their child's difficulties. As one mother recently related to me: "Once my son was diagnosed as A.D.D., it was like a giant burden was lifted off of me, and we finally knew what was going on with him."
The A.D.D. label serves as a neutral term that helps to organize all the contradictory elements in these children's lives. Moreover, it does this without blaming anyone. Like its older cousin - learning disabilities (LD) - "A.D.D." comes to us dressed in the cloak of scientific respectability. A report by a federal commission on the needs of children in the 1970s could have substituted "A.D.D." for "LD" in its own assessment of the user-friendliness of the label when it concluded: "The term learning disabilities [read: A.D.D.] has appeal because it implies a specific neurological condition for which no one can be held particularly responsible.... There is no implication of neglect, emotional disturbance, or improper training or education.... For these cosmetic reasons, it is a rather nice term to have around."
The A.D.D. label also provides a central point around which parents, teachers, and professionals can rally for political and economic support. We've already seen in the last chapter how a lobbying effort by an A.D.D. advocacy group helped to secure an informal place for A.D.D. in existing laws regarding disabled children. Teachers who are disturbed by a child's behavior can now petition to have him removed to a special classroom. Parents can press to have their A.D.D. children taught in expensive private schools at public school expense and sue if they feel their children aren't being given an appropriate education.
The danger in all of this is that children may be stigmatized by a label that could haunt them for the rest of their lives. Attention deficit disorder, after all, is a psychiatric disorder. In times past, mental illnesses such as schizophrenia were reserved for the extremes in human behavior. With prevalence statistics for A.D.D. running from 1 to 20 percent and higher, however, millions of kids could be threatened with the prospect of joining the ranks of the psychiatrically disturbed.
The A.D.D. label creates unintended side effects that are anything but positive. Research over the past twenty-five years has consistently supported the existence of what has been called "the self-fulfilling prophecy." That is, what you expect from a child, you often get as a result of your expectations. Thus, if you expect a child to do well, then the child will tend to rise to your high expectations. On the other hand, if a parent or teacher sees a child as "disordered," (e.g., A.D.D.) then the child will tend to modify his behavior to that expectation. Studies reveal that teachers may not teach as effectively to children perceived as having learning problems, even when those children are actually "normal." Recent research suggests that the self-fulfilling prophecy may work in peer relationships as well. In one study, children were paired and given instructions to work with Lego building blocks and drawing materials. When a normal child was told in advance that his partner had a "behavior problem," his interaction with the partner was disturbed, even when the so-called problem child was actually normal.
Major educational and civic groups opposing A.D.D. as a new school label have underscored these concerns about stigmatizing children. Former president of the National Association of School Psychologists Peg Dawson commented, "We don't think that a proliferation of labels is the best way to address the A.D.D. issue. It's in the best interest to all children that we stop creating categories of exclusion and start responding to the needs of individual children." Similarly, in response to a 1991 request by the federal government for more information about the A.D.D. controversy, Debra DeLee, a spokesperson for the National Education Association, the largest organization in the country for teachers, wrote: "Establishing a new category [A.D.D.] based on behavioral characteristics alone, such as overactivity, impulsiveness, and inattentiveness, increases the likelihood of inappropriate labeling for racial, ethnic, and linguistic minority students."
Proponents of A.D.D. are aware of the many criticisms leveled against it, and have engaged in what I'd like to call "definition management," in response. As part of a 1993 fund-raising letter to members of the parent advocacy organization CH.A.D.D., then-president Bonnie Fell made reference to a professor who had questioned the existence of A.D.D. in The Wall Street Journal as if such a criticism could hardly be conceivable in a person of intelligence (Fell writes: "Yes, he's a university professor! In the Wall Street Journal!"). Later on in the letter, she writes: "I'm going to stop writing now, but I know I won't be able to stop worrying - not when press reports of two recent court cases have highlighted the attempts of defense attorneys to blame convicted murderers' actions on A.D.D. . . ."
A.D.D. proponents like Ms. Fell seem to be steering a middle course for A.D.D. between the Scylla of normality (A.D.D. is something that everybody has to one extent or another) and the Charybdis of extreme pathology (A.D.D. can lead people to Satan worship, animal mutilation, and even murder). Such a strategy seems to be based on the belief that if A.D.D. is seen as too much a part of normal behavior, then it could run the danger of losing its tenuous disability status as well as the substantial financial support that comes from donors wishing to help the handicapped. On the other hand, if A.D.D. is seen as linked to too much pathology, then parents won't want to have their children associated with the label. Ultimately, then, when we look deep into the heart of the A.D.D. movement, what we discover at its core is that A.D.D. is as much a public relations effort as anything else. That the lives of millions of children should be guided by such a flimsy notion certainly should give us cause for great concern.
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